mortality remains high for STEMI patients

Mortality Remains High for STEMI Patients Complicated by Cardiogenic Shock

December 2, 2016

Key Takeaways

  • Early reperfusion for STEMI patients complicated by cardiogenic shock results in lower mortality compared to prolonged reperfusion.
  • Shorter onset-to-balloon (OTB) and door-to-balloon (DTB) times are recommended to improve patient survival.
  • A shorter OTB was associated with longer overall survival in patients vs prolonged OTB (43.3% and 55.5%, respectively).
  • Mortality rates for short vs long DTB in this study were 44.9% and 55.8%, respectively.

The significant reduction of in-hospital mortality related to ST-segment elevation acute myocardial infarction (STEMI) has been greatly attributed to the overwhelming adoption of primary percutaneous intervention (PCI). STEMI patients with cardiogenic shock (CS) tend to experience a higher mortality even after PCI and the implantation of mechanical circulatory support (MCS) devices.

A recent retrospective study published in European Heart Journal: Acute Cardiovascular Care assessed the mortality benefit, if any, of reperfusion via primary PCI for patients with STEMI complicated with CS of 466 patients enrolled in the Coronary Revascularization Demonstrating Outcome Study in Kyoto (CREDO-Kyoto) acute myocardial infarction (AMI) registry.

For the purpose of this study, CS was defined by the following Killip class IV criteria:

  • Systolic blood pressure < 90 mmHg
  • Vasoconstriction manifestations
    • Cyanosis
    • Diaphoresis
    • Oliguria

To evaluate the primary outcome measure of all-cause mortality for these patients, researchers looked at the cumulative incidence of all-cause death in the patients with STEMI complicated by CS due to acute pump failure. The recorded incidence was as follows:

  • 25.4% at 30 days
  • 38.7% at 12 months
  • 51.4% at five years

Researchers found that a shorter onset-to-balloon (OTB) time (< 3 hours) resulted in a significantly lower rate of death (Figure 1) compared to prolonged OTB (43.3% and 55.5%, respectively). There were similar findings between short and long door-to-balloon (DTB) time (44.9% vs 55.8%, respectively). Additionally, early reperfusion was associated with a lower rate of mortality.

Figure 1. All-Cause Mortality of Short and Prolonged (a) OTB and (b) DTBa
long term clinical outcomes
aData from Kawaji, Shiomi, Morimoto, et al.1

While the patient population used in this study was relatively small (n=3942), the data shows mortality rates continue to remain high among patients with STEMI complicated with CS caused by acute pump failure. Implementing shorter OTB and DTB times, at least according to this study, may result in improved long-term survival.

Reference:

  1. Kawaji T, Shiomi H, Morimoto T, et al. Long-term clinical outcomes in patients with ST-segment elevation acute myocardial infarction complicated by cardiogenic shock due to acute pump failure. Eur Heart J Acute Cardiovasc Care. 2016.

Impella® Device — Indication & Safety Information

INDICATIONS FOR USE

Protected PCI

The Impella 2.5® and Impella CP® Systems are temporary (≤ 6 hours) ventricular support devices indicated for use during high-risk percutaneous coronary interventions (PCI) performed in elective or urgent, hemodynamically stable patients with severe coronary artery disease, when a heart team, including a cardiac surgeon, has determined high-risk PCI is the appropriate therapeutic option. Use of the Impella 2.5 and Impella CP Systems in these patients may prevent hemodynamic instability, which can result from repeat episodes of reversible myocardial ischemia that occur during planned temporary coronary occlusions and may reduce peri- and post-procedural adverse events.

Cardiogenic Shock

The Impella 2.5®, Impella CP®, Impella 5.0®, and Impella LD® Catheters, in conjunction with the Automated Impella Controller (collectively, “Impella® System Therapy”), are temporary ventricular support devices intended for short term use (≤ 4 days for the Impella 2.5 and Impella CP, and ≤ 6 days for the Impella 5.0, and Impella LD) and indicated for the treatment of ongoing cardiogenic shock that occurs immediately (< 48 hours) following acute myocardial infarction or open heart surgery or in the setting of cardiomyopathy, including peripartum cardiomyopathy, or myocarditis as a result of isolated left ventricular failure that is not responsive to optimal medical management and conventional treatment measures (including volume loading and use of pressors and inotropes, with or without IABP). The intent of Impella System Therapy is to reduce ventricular work and to provide the circulatory support necessary to allow heart recovery and early assessment of residual myocardial function.

Important Risk Information for Impella devices

CONTRAINDICATIONS

The Impella 2.5, Impella CP, Impella 5.0 and Impella LD are contraindicated for use with patients experiencing any of the following conditions: Mural thrombus in the left ventricle; Presence of a mechanical aortic valve or heart constrictive device; Aortic valve stenosis/calcification (equivalent to an orifice area of 0.6 cm2 or less); Moderate to severe aortic insufficiency (echocardiographic assessment graded as ≥ +2); Severe peripheral arterial disease precluding placement of the Impella System; Significant right heart failure*; Combined cardiorespiratory failure*; Presence of an Atrial or Ventricular Septal Defect (including post-infarct VSD)*; Left ventricular rupture*; Cardiac tamponade*

* This condition is a contraindication for the cardiogenic shock indication only.

POTENTIAL ADVERSE EVENTS

Acute renal dysfunction, Aortic valve injury, Bleeding, Cardiogenic shock, Cerebral vascular accident/Stroke, Death, Hemolysis, Limb ischemia, Myocardial infarction, Renal failure, Thrombocytopenia and Vascular injury

In addition to the risks above, there are other WARNINGS and PRECAUTIONS associated with Impella devices. Visit http://www.abiomed.com/important-safety-information to learn more.

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